Demographics, HIV/AIDS and Reproductive Health: Implications for the Achievement of the MDGs

Statement by Thoraya Ahmed Obaid UNFPA Executive Director

Good afternoon.

It is my pleasure and honour to join you today to discuss the very important topic of demographics, HIV/AIDS, reproductive health and their implications for the achievement of the Millennium Development Goals (MDGs).

I will not keep you in suspense. Rather, I will inform you right from the start that demographics, HIV/AIDS and reproductive health must be more forcefully addressed if we are to achieve the MDGs. And the reason is quite simple: These issues are central to success and, if they are not addressed, the MDGs will be another set of targets missed.

Before I make my case, I would like to thank the Overseas Development Institute (ODI) and its Director, Simon Maxwell, and the All-Party Parliamentary Group on Population, Development and Reproductive Health, and Christine McCafferty and Tony Worthington, for inviting me and for bringing us together to discuss these vital issues. It is a pleasure to share the podium with John Cleland.

It is particularly useful that we meet just a few weeks following the launch of the report of the Millennium Project. As you know, the United Nations Millennium Project is the independent advisory body commissioned by the United Nations Secretary-General, to propose the best strategies for meeting the MDGs. These goals are to:

1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability, and
8. Develop a global partnership for development.

To foster progress, the Millennium Project brought together more than 250 experts from around the world – including development practitioners, national and international policy makers, as well as civil society and private sector representatives – to identify best practices and to plot the way forward.

On 17 January, the team launched its reports and I would like to highlight some of their key findings and recommendations in line with the theme of today’s meeting.

In terms of demographics, the Millennium Project team concluded that there are strong links between rapid population growth, high fertility, ill-timed pregnancies and poverty. In fact, they pointed to the existence of what they called “a demographic-related poverty trap”. The poorest people have the highest fertility and the largest families. This is due in large part to the fact that they have the least access to information and services for family planning. In order to break out of the poverty trap, one of the things they need is reproductive health and rights, including voluntary family planning, so that they can time and space their births and can invest more of their resources in the health and education of each child, and thereby break the cycle of poverty that runs from one generation to the next.

Another finding is that each region’s prospects for progress towards the MDGs are affected by its demographic conditions. Poorer countries are more likely to have demographic regimes marked by high fertility and high mortality, resulting in large youth populations with low adult ratios. They go on to say that such demographic profiles are associated with greater risks of conflict.

As you may recall, there was a study done on this over a year ago by Population Action International, entitled, The Security Demographic. The findings of the report suggested that the risks of civil conflict that are generated by demographic factors may be much more significant than generally recognized, and worthy of more serious consideration by national security policy makers and researchers. Its conclusions, drawn from a review of literature and analyses of data from 180 countries, argue that:

• Recent progress along the demographic transition—which is a population’s shift from high to low rates of birth and death—is associated with continuous declines in the vulnerability of nations to civil conflict.
• If this association continues through the 21st century, then a range of policies promoting small, healthy and better-educated families and long lives among populations in developing countries seems likely to encourage greater political stability in weak states and to enhance global security in the future.

So, clearly there are demographic factors that must be addressed in order to achieve the MDGs. There is no doubt that the dynamics of human population—the rates of growth, age structure, distribution, fertility and mortality, migration and more—influence every aspect of social and economic development. There is also no doubt that sexual and reproductive health services, including family planning, exert a powerful influence on demographics and population trends.

The Millennium Project team concluded that ensuring access to sexual and reproductive health information and services, including voluntary family planning, is essential for achieving the MDGs. They concluded that gender equality cannot be achieved without guaranteeing women’s and girls’ reproductive rights. And they stated that governments should incorporate universal access to reproductive and sexual health services and information as an integral part of their responses to AIDS.

All of these findings and conclusions reinforce the integrity and vision of the agreement that was reached 10 years ago in Cairo at the International Conference on Population and Development (ICPD) and at the 1999 five-year review. At the Cairo Conference, 179 governments agreed that population dynamics and trends should be carefully analysed as a basis for social and economic development policies, plans and programmes.

The Programme of Action adopted in Cairo recognized the right to sexual and reproductive health, and the empowerment of women and gender equality as decisive factors in the forces needed to facilitate development and reduce poverty. And governments agreed on the need to ensure universal access to reproductive health services by the year 2015.

And, yet, despite the relevance of reproductive health, the need for universal access to it is not included as one of the eight MDGs and it is not included in the 18 targets that have been set to achieve them.

This glaring omission has prompted some activists, journalists and policy makers to call access to sexual and reproductive health the missing link. But if we have our way, it will not be missing for long.

The links are clear and they are many.

There is solid evidence that increasing access to reproductive health services, including family planning and sexual health, reduces poverty within families and within nations.

Due to the spread of family planning programmes, women in the developing world today have an average of 4 children compared to 6 just 25 years ago. They are better able to give each child education and health care, which helps break the cycle of poverty.

The use of family planning in the developing world has increased from 38 per cent of women in the 1970s to 52 per cent. This constitutes a demographic revolution that has literally changed the face of the Earth. Today, there are 6.4 billion people and the United Nations projects that there will be 8.9 billion people on the planet, Earth, by the year 2050. This projection is 400 million smaller than what experts had predicted a few years ago—a change in projection due to two factors. One is the increasing impact of HIV/AIDS and rising death rates, particularly in sub-Saharan Africa, where life expectancy in several countries is declining, and hard-won gains in development are being wiped away. The other factor is a positive one—the increased use of family planning, resulting in less unwanted pregnancy.

Overall, population growth is slowing, but it is by no means over. Each year, 77 million people are added to the planet, 146 every minute. Between now and 2050, eight countries—India, Pakistan, Nigeria, the United States, China, Bangladesh, Ethiopia and the Democratic Republic of the Congo—are expected to account for half of the world’s population increase. By far the highest growth rates will occur in the world’s poorest nations, where population will nearly triple in the next 45 years. This is a cause of concern because these are the countries with the least access to information and services, the lowest use of family planning and the highest fertility and mortality rates.

I would also like to point out that, despite the devastation caused by AIDS, most of the countries affected in Africa will continue to experience population growth in the coming decades due to high fertility levels. It is only in the hardest-hit countries of Botswana, Lesotho, South Africa and Swaziland that outright reductions in population are projected.

All nations need quality reproductive health services because the benefits of these investments are enormous. At the national level, investments in reproductive health and family planning produce what is called a “demographic bonus”. This is spurred by lower rates of fertility and mortality, and a large healthier working population with relatively fewer dependants to support. This bonus results in higher productivity, savings and economic growth. The demographic bonus in East Asia is estimated to account for about one third of the region’s unprecedented economic growth during 1965-90. So, there are clear links between reproductive health and poverty reduction.

The links between reproductive health and rights and gender equality and the empowerment of women are also strong and well established. The ability of women to control their own fertility is absolutely fundamental to women’s empowerment and equality. When a woman can plan her family, she can plan the rest of her life. When she is healthy, she can be more productive. And when her reproductive rights—including the right to plan her family in terms of birth timing and spacing, and to make decisions regarding reproduction free of discrimination, coercion and violence—are promoted and protected, she has freedom to participate more fully and equally in society.

Reproductive Rights Are Essential to Women’s Advancement

Reproductive health and family planning also play a key role in another MDG—reducing child mortality. A healthy mother is the first step towards a healthy child. A leading cause of infant and child mortality is poor maternal health. Today, poor maternal health care causes nearly half, nearly half, of all infant deaths. Each year, more than 4 million newborn children die during the first month of life, and 4 million more are stillborn. And many of these deaths are due to complications their mothers experienced during pregnancy or childbirth. So, clearly reproductive health is absolutely essential to reducing child mortality. It is also well-known that when a mother dies, the newborn child faces a much higher risk of death—as much as 10 times higher than one with a living mother.

Reproductive health and rights are also essential to improving maternal health. Today, the highest proportion of women’s ill-health burden is related to their reproductive role. Sexual and reproductive ill health accounts for one third of the global burden of disease amongst women of reproductive age in the developing world; it is a leading cause of death for women. This has high economic and social costs, as the Commission on Macroeconomics and Health of the World Health Organization has described. Each year, millions of children are left without their mothers.

Today, a woman in sub-Saharan Africa faces a 1 in 16 chance of dying during pregnancy and childbirth, compared to 1 in 2,800 for a woman in developed nations. This is simply outrageous because we know how to prevent these needless deaths. To close this gap, women need:

• Family planning,
• Antenatal and post-natal care,
• Skilled attendants at birth, and
• Emergency obstetric care.

Because these basic reproductive health services are not more widely available, accessible and affordable, more than half a million women die each year from complications of pregnancy and childbirth. They are denied the very basic right to life, let alone the right to health. Universal access to reproductive health services would save women’s lives and the lives of their children, and allow us to achieve key Millennium Development Goals.

If modern contraceptive services were available to all 201 million women with unmet needs in the developing world, the number of unplanned births would decline by 72 per cent and 1.5 million lives would be saved each year. The World Bank estimates that, if 99 per cent of women had access to professionally delivered care, up to 74 per cent of current maternal deaths could be averted. Today, just half of the women in developing countries have the assistance of birth attendants at the time of delivery.

We must also increase access to reproductive health services to combat HIV and AIDS. With over 75 per cent of HIV cases due to sexual transmission, sexual and reproductive health care is a strategic entry point for maximizing the impact of HIV/AIDS prevention efforts. There is wide recognition that these services provide an important opening for HIV prevention and testing, as well as for preventing and treating other sexually transmitted infections, which can increase the risk of HIV infection by a factor of two to nine. This is especially important for women, who are experiencing rising HIV infection rates in every region.

• Over the past two decades, the percentage of women among adults living with HIV has risen from 35 to 47 per cent worldwide.
• Young women are hit hardest—globally, young women represent over 60 per cent of all 15-24-year-olds living with HIV.
• In some parts of Africa, young women make up 75 per cent of all new infections in this age group.
• In at least two of the continent’s main cities, the rate of HIV infection among young women is seven times as great as the rate among men.
• In South Asia, young women account for 62 per cent of infections in the 15-24 year-old age group.

These figures suggest that young women are virtually becoming “endangered species” in some high-prevalence countries. They also provide an urgent reality check that our current efforts to help women and girls protect themselves from AIDS are not working. And I would like to stress that I am not just talking about health services, I am also talking about the protection of women’s human rights and concrete action to address gender discrimination and violence, which fuel the spread of AIDS. Linking or integrating reproductive health and HIV services is the only way to scale up responses, to reach the largest number of women and young people, and to optimize the use of available human, financial and institutional resources.

In this regard, I must mention the work that was done here in Britain on this issue. I would like to thank the All-Party Parliamentary Group for conducting research, and holding parliamentary hearings on linking sexual and reproductive health and HIV/AIDS. Your work has made a significant contribution, and the British Government’s comprehensive and forward-looking international HIV/AIDS policy reflects this. Linking reproductive health and HIV/AIDS funding, policies and services is the only way we will make greater progress in reversing the spread of the pandemic and also in meeting other key MDGs, such as reducing poverty and maternal and child mortality.

Let me tell you a story to illustrate what I am talking about. Last year, the United States Centers for Disease Control and Prevention (CDC) conducted a study of some 500 women in maternal health clinics in Botswana, where free HIV testing and anti-retroviral therapy were being provided by the Government. As you know, Botswana has the highest HIV prevalence rate in the world, with nearly 40 per cent of adults infected. The study found that many of the women were reluctant to be tested even though free treatment was being provided. But even more shocking was the finding that 61 per cent of the women said that their pregnancies were unintended. (Surveys show that 38 per cent of married women in Botswana use modern contraception.) This finding of 61 per cent prompted the CDC to advocate the inclusion of voluntary family planning in all efforts to address HIV/AIDS. Of course, the CDC is right. We must approach these issues with a comprehensive strategy that meets people’s needs. And this comprehensive approach is embraced in the very concept of reproductive health and rights.

The United Nations has endorsed a four-pronged approach to preventing mother-to-child transmission, which includes:

1. Preventing primary HIV infection in women,
2. Preventing unintended pregnancies in women with HIV infection,
3. Preventing transmission from HIV-infected pregnant women to their infants, and
4. Providing care, treatment and support for HIV-infected women and their families.

Ladies and Gentlemen,

I have outlined some of the reasons why population and demographics and reproductive health must be addressed to achieve the MDGs. But allow me now to be more specific in what we must do to ensure that these issues ARE addressed and given the priority they deserve.

Just how far the world has come in reaching the MDGs will be measured this year during the five-year review of the Millennium Declaration. As you may know, the United Nations Secretary-General is now preparing a report on the subject, which will be released in March. And all efforts will culminate at a summit meeting in the General Assembly in September at which key actions for the next decade will be laid out.

I can assure you that my agency, UNFPA, the United Nations Population Fund, and its partners in government and civil society will continue efforts to ensure that the issues of population and reproductive health and rights are given prominence in all the various reports and declarations that are forthcoming.

Last October, I had the honour of meeting with European Union (EU) ministers of development cooperation. Like their counterparts in other regions, they showed keen appreciation of our work and its contributions to development. This view was later reflected in the EU Council conclusions on the Cairo consensus, which called for the Cairo Programme of Action to be central to the high-level review of the implementation of the Millennium Declaration. So, this is an important step forward.

Another important step will take place this coming April. There will be a high-level meeting in Stockholm with ministers of finance and development from both developed and developing countries, to increase awareness, commitment and funding for sexual and reproductive health as a critical development investment.

This is extremely important because at this point, some voices say that population and reproductive health and rights are nowhere to be found in the actual Millennium Declaration and the Millennium Development goals. And these issues should be accorded great priority.

We must act with urgency and with a single-minded purpose. As Secretary-General Kofi Annan has stated: “The Millennium Development Goals, particularly the eradication of extreme poverty and hunger, cannot be achieved if questions of population and reproductive health are not squarely addressed. And that means stronger efforts to promote women’s rights, and greater investment in education and health, including reproductive health and family planning.”

Luckily, the reports of the Millennium Project that were launched on 17 January establish the importance of these issues and provide us with a solid foundation on which we must build to place population and reproductive health issues more firmly within the MDG framework and processes.

But, of course, much more needs to be done. Today, too many women have no access to reproductive health care, especially if they are poor. Too many women die of preventable pregnancy- and childbirth-related causes. Too many women and girls are subject to sexual exploitation and abuse. AIDS, which has already claimed the lives of some 20 million people, 15 million of them in Africa, continues to spread, with infections rising in Eastern and Central Europe and Asia. Today, nearly 40 million individuals are living with HIV/AIDS, and there are 15 million AIDS orphans. The social, political, demographic and economic impact is beyond comprehension.

Population and reproductive health and rights are at the heart of these challenges. The MDGs will be that much easier to achieve if commitments on population and reproductive health are met.

In July, the United Kingdom will host a summit meeting of industrial countries that will spotlight poverty, particularly in Africa. Prime Minister Tony Blair has appointed a Commission on Africa that is to report in a few months, and the Chancellor of the Exchequer, Gordon Brown, is campaigning for a ''Marshall Plan'' for Africa that includes debt relief and his own proposal to nearly double aid from rich nations. Part of this investment must be made in reproductive health.

The price of inaction—roughly 2.5 million maternal deaths, 7.5 million child deaths and 49 million maternal injuries in the next 10 years…in Africa alone—is too high to contemplate.

UNFPA is catalysing and supporting efforts to ensure that reproductive health and rights are an integral part of MDG processes and frameworks at the national and international levels. We are working to develop national capacity and to mobilize the necessary political and financial support. We are working with partners to ensure that universal access to reproductive health is reflected in the MDG targets. In fact, the Millennium Project has recommended that universal access to reproductive health services by 2015 through the primary health care system be added as a target to the goal of improving maternal health. We are also working to ensure that the indicators list for monitoring MDGs is revised. And, here again, the Millennium Project has made recommendations. The Project team has recommended that additional indicators—on contraceptive prevalence rate, the proportion of births attended by skilled attendants, availability of emergency obstetric care, adolescent fertility rate, and proportion of demand for family planning satisfied—be added to various MDGs.

My friends,

Behind all of these numbers and targets are human beings who yearn for a better life. If we are serious about halving poverty and achieving the MDGs, sexual and reproductive health must be addressed. This is particularly important, given the world’s largest youth generation. The choices and opportunities they have will determine our common future.

Thank you.